This is a different kind of star power – unlike that of Clark Gable or Marilyn Monroe. This is the power of self-checking using STAR technique where one stops for a second, thinks before acting, and reviews whenever one has the chance.

An experimental plane sputtered after take-off Monday, 2 April 2012 and crashed in the Publix grocery store in DeLand, FL (near Orlando). The pilot and passenger were badly injured. 100 people were in the store although only five were injured badly enough to be seen in hospital. 

Capital One’s ubiquitous television commercials end by posing the question “what is in your wallet?” A simple question that should have a simple answer. Money is easy to count, and as a result, healthcare leaders are very proficient in managing finances. In fact, patient safety leaders have observed that safety would be more readily improved if harm were easier to count – as easy to count as money.

A colleague of ours, Jim Morrison, CDR USCG (RET), recently shared the story of the grounding of the cruise ship Royal Majesty (inset right) on the Nantucket shoals 9 June 1995. As Jim recounted the story to illustrate Weick & Sutcliffe’s five principles of high reliability organizations, I realized that the grounding of the Royal Majesty was a metaphor for the CEO role in leading patient safety culture. A CEO captains the healthcare system much like the ship’s captain runs the ship.

 Never turn your back to the sea. This is good advice for sailors, surfers, beach combers, and now – nuclear power safety analysts! Inserted below is a link to the Institute for Nuclear Power Operations (INPO) report on the tsunami-induced core damage events at the Fukushima nuclear power stations in Japan. (You can still read our initial impressions of the Fukushima accident(s) as an HPIShare in our blog archives.) Here is the link to the INPO report:

Anne Clapper, our 13-year-old daughter who you might remember as winning the diving gold medals at the Grand Canyon State games, has again taught me something about human performance in complex systems. Anne (shown leaping in the inset photo) competed in a regional dance competition in Mesa, Arizona.

Extra, extra, read all about it! That would be a good line for me – my family name comes from the tongue of the bell, and our ancestral family profession was ringing the bell and reporting the news. And here is the big news – our Steve Kreiser just published in the online edition of the Patient Safety and Quality Journal a comprehensive analysis of CRM history, fundamentals, and applications to healthcare teams:

Dr Stewart Hamilton (inset right) would fit well into the lyrics of Alanis Morissette’s song Ironic. Perhaps right between the lines of “it’s like rain on your wedding day” and “a free ride when you’ve already paid.”

Dr Hamilton died 29 July 2002 in his own hospital, Hartford Hospital in Connecticut, from complications of a MRSA infection likely contracted after being admitted for treatment of a minor head laceration. He fell at home and hit his head on the dishwasher, causing a 2-inch cut. His wound was closed in the ED with staples, and he stayed overnight in the hospital for observation.

The year 2011 has come to an end – and 2012 is just underway. The books are now closed on the number of patient deaths caused by poor care in 2011. If the estimate published in the IOM report - To Err is Human - is accurate, the meter would read 98,000 patient deaths for the year. That would be one patient death every 5 minutes, 22 seconds. In the time you take to reflect on this message, another patient will have died because of errors and omissions in their care.

Sebastian Ferrero – we barely had a chance to know you. Sebastian, then five years old, died 10 October 2007 at the Shands HealthCare Alachua General Hospital (AGH) in Gainesville, FL when a dispensing error, poor patient monitoring during medication administration, clinicians slow to listen to the mom, and a misread CT scan combined to take his life as it barely started.